Revision total hip arthroplasty after two liver transplantations: A case report

Abstract

BACKGROUND

Revision total hip arthroplasty (THA) in liver transplant recipients is rare and represents a significant clinical challenge owing to chronic immunosuppression, multiple comorbidities, and increased perioperative risk. Careful assessment of comorbidities and multidisciplinary perioperative management are essential to optimize clinical outcomes in this high-risk population.

CASE SUMMARY

We report the case of a 77-year-old man with a history of hepatic failure due to decompensated chronic hepatitis B infection who underwent two liver transplantations. The patient presented with recurrent dislocation of a right hip prosthesis and a periprosthetic fracture, accompanied by significant pain and limb shortening. Multidisciplinary preoperative optimization was performed. Revision THA was performed successfully. Postoperatively, the patient demonstrated improved mobility and reduced pain. At 6 months after surgery no recurrent dislocation, periprosthetic infection, or implant-related complication was observed, and liver graft function remained stable. The Harris Hip Score was 68, the Visual Analog Scale score was 0, and the Short Form-12 score was 18. Despite multiple risk factors for osteoporosis, densitometry did not confirm reduced bone mineral density.

CONCLUSION

Revision THA in liver transplant recipients can be successful despite high perioperative risk. Individualized multidisciplinary management and careful perioperative planning are essential to functional outcomes in this complex patient population.

Key Words: Total hip arthroplasty; Liver transplantation; Periprosthetic fracture; Prosthesis dislocation; Immunosuppression; Multidisciplinary care; Case report

Core Tip: Revision total hip arthroplasty (THA) after liver transplantation (LT) is extremely rare and represents a major clinical challenge due to chronic immunosuppression, multiple comorbidities, and a high risk of perioperative complications. We present a case of a patient who previously underwent two LT for chronic hepatitis B and later required revision THA owing to recurrent prosthesis dislocation and periprosthetic fracture. Clinical outcomes were assessed using functional scales, including the Harris Hip Score and the Visual Analog Scale for pain, demonstrating significant postoperative improvement. This case highlights the importance of multidisciplinary management and careful perioperative planning in high-risk transplant recipients.

INTRODUCTION

The increasing prevalence of total hip arthroplasty (THA) requires careful consideration and management among patients undergoing these procedures. As the rate of hip replacements rises, it is essential to assess the impact of concurrent diseases and medical conditions on clinical outcomes, complications, and overall patient recovery. Comprehensive risk stratification, including evaluation and optimal management of comorbidities, is crucial for improving patient care and optimizing outcomes related to arthroplasty procedures[1]. Additionally, it is important to recognize the high risk of fractures in older patients with secondary osteoporosis, which is not always diagnosed and treated on time[2].

Patients who have undergone liver transplantation (LT) and require THA may experience functional benefits after surgery; however, they also face increased risks, including infection and the need for revision or reoperation. LT recipients require lifelong immunosuppressive treatment, including calcineurin inhibitors (tacrolimus), inhibitors of de novo purine synthesis that block the proliferation of both B- and T- lymphocytes (mycophenolate mofetil), and, in some cases, corticosteroids such as prednisolone to prevent organ rejection. Studies have shown that higher doses of prednisolone, especially those exceeding certain thresholds, significantly increase the risk of fractures in these patients[3].

Additionally, short-term mortality may pose a concern in this population. The increasing demand for THA among LT recipients underscores the necessity of carefully evaluating each patient’s risk profile before surgery, as existing studies show significant variability in outcomes. A thorough assessment of transplant history and overall health status is crucial for optimizing surgical success and minimizing complications in this unique patient group[4].

CASE PRESENTATION

Chief complaints

A 77-year-old patient was admitted to the Department of Orthopaedics and Trauma Surgery at the District Hospital in Piekary Śląskie on September 1, 2024, for planned surgical treatment of recurrent dislocation of a right hip prosthesis associated with a periprosthetic fracture. The patient reported significant pain in the right hip area and demonstrated marked shortening and external rotation of the right leg, as well as a significant pressure ulcer in the right gluteal region.

History of present illness

On June 10, 2024, the patient suffered a fracture of the right femoral neck as a result of a fall from standing height. On the day of surgery, June 14 2024, laboratory test results revealed a significantly elevated serum C-reactive protein (CRP) level of 125 mg/L (normal range: < 5 mg/L) and a moderately decreased serum sodium level of 130 mmol/L. A planned THA was performed using cementless components, including a 56-mm Trident cup, an Accolade stem, and Dall-Miles cable fixation (Figure 1). On June 19, the patient was discharged with recommendations for analgesic therapy and dabigatran. Almost a week after being discharged from the orthopaedic ward, the patient was admitted to the neurology department of another hospital owing to severe weakness and dizziness that had been progressively worsening over several days, along with a general deterioration in his overall condition.

Figure 1 Radiographic findings before and after revision total hip arthroplasty. A: Anteroposterior (AP) radiograph of the right hip joint after cementless total hip arthroplasty (THA), showing the presence of a stabilizing loop; B: AP radiograph of the pelvis showing dislocation of the right hip endoprosthesis and status after THA on the left side; C: AP radiograph of the pelvis after revision THA on the right, showing heterotopic ossification around the implant and status after THA on the left side.

Laboratory tests revealed severe hyponatremia (serum sodium level of 109 mmol/L) and a urinary tract infection caused by Enterococcus faecalis. An endocrinology consultation was obtained, and based on the laboratory findings and clinical evaluation, the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was diagnosed. During hospitalization, targeted antibiotic therapy was initiated, and treatment of hyponatremia with hypertonic saline solutions was continued. The patient was subsequently discharged to home.

On an outpatient basis, treatment of recurrent hyponatremia with a selective vasopressin V2 receptor antagonist (tolvaptan) was initiated, with satisfactory results.

On July 29, the patient was readmitted to the orthopaedic ward owing to dislocation of the hip endoprosthesis and loosening of the stem (Figure 1). Laboratory findings revealed elevated inflammatory parameters, including a serum CRP level of 82 mg/L. A planned procedure of closed reduction of the dislocated hip endoprosthesis was performed in the operating theatre. The patient was discharged on July 31 with recommendations for analgesic therapy and anti-decubitus ointments. On August 9, the patient presented to our centre (Department of Orthopaedics and Trauma Surgery, District Hospital in Piekary Śląskie) for consultation. Radiographic examination revealed dislocation of the right hip endoprosthesis with a concomitant periprosthetic fracture. Given the patient’s multiple comorbidities, a multidisciplinary team meeting was convened, and comprehensive consultations with specialists from hepatology, cardiology, neurology, and anaesthesiology were planned.

History of past illness

The patient had a significant medical history, including multiple surgeries and chronic comorbidities. Of particular importance, he had previously been diagnosed with chronic hepatitis B infection at the stage of decompensated liver cirrhosis, which progressed to hepatic failure despite antiviral therapy and ultimately required two LT in 1998 and 1999.

Immunosuppressive treatment with tacrolimus and low-dose prednisone was initiated immediately after the first LT and has been continued to date with dose modifications. Regarding the patient’s hepatitis B virus (HBV) infection and virological status, prophylactic treatment was initiated immediately after the first LT with hepatitis B immunoglobulins and the oral nucleoside analogue lamivudine, with good results. Serum levels of both hepatitis B serum antigen and HBV-DNA remained negative, indicating no active viral replication.

Laboratory liver function tests, including serum alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase activities, as well as bilirubin and albumin levels, were within normal ranges, indicating preserved graft function.

In addition to orthopaedic conditions, the patient had multiple comorbidities, including decompensated chronic heart failure (NYHA Class III/II), generalized atherosclerosis, recurrent hyponatremia secondary to SIADH, type 2 diabetes mellitus managed with insulin, polyneuropathy, dyslipidaemia, a history of stroke, a history of encephalitis, depressive disorder, secondary anaemia, and stage II pressure ulcers located in the upper gluteal cleft and on the right heel. Some of the patient’s comorbidities and medications may have contributed to the development of secondary osteoporosis. Mobility limitations resulting from a previous stroke and recurrent hyponatremia increased the risk of falls from standing height, predisposing the patient to osteoporotic fractures and hip prosthesis dislocation. Chronic hyponatremia may also contribute to the development of osteoporosis.

Long-standing type 2 diabetes mellitus, with complications such as sensorimotor polyneuropathy and prior ischemic stroke, further increased the risk of falls. Insulin therapy, which predisposes to hypoglycaemia, combined with neuropathic sensory deficits and post-stroke weakness, contributed to the likelihood of injury and recurrent fractures. Because of the need for urgent orthopaedic surgery, preoperative consultations with specialists in neurology, hepatology, cardiology, and diabetology were prioritized, while osteoporosis assessment and management were postponed until the postoperative period and conducted alongside rehabilitation.

Personal and family history

The patient had no relevant family history.

Physical examination

Upon examination, the patient reported significant pain in the right hip region. Notably, considerable shortening of the right lower limb by 10 cm was observed, accompanied by external rotation of the limb. The surgical wound from the right hip arthroplasty was well healed, with sutures removed and no signs of inflammation. A stage II pressure ulcer was present in the upper right gluteal cleft. Muscle strength in the right lower limb was reduced, assessed as Lovett grade I/II. Sensation and blood circulation in the distal portion of the right leg were intact. A complete loss of active range of motion in the right hip joint was noted.

Laboratory examinations

Laboratory test results revealed a significantly elevated serum CRP level of 125 mg/L and moderately decreased serum sodium of 130 mmol/L (normal range: 136-145 mmol/L). During neurological hospitalization, severe hyponatremia was detected, with a serum sodium level of 109 mmol/L.

Subsequent laboratory findings later demonstrated elevated inflammatory markers, including a serum CRP level of 82 mg/L. Liver function test findings were within the normal ranges.

Imaging examinations

Radiographic examination revealed a fracture of the right femoral neck. Subsequent imaging demonstrated dislocation of the right hip endoprosthesis with loosening of the stem, followed by recurrent dislocation with a concomitant periprosthetic fracture. Imaging also showed heterotopic ossification around the implant following the arthroplasty procedure, as well as status after THA on the left side.

MULTIDISCIPLINARY EXPERT CONSULTATION

Owing to multiple comorbidities and previous LT, a multidisciplinary expert consultation was performed before revision arthroplasty. Specialists in hepatology, neurology, cardiology, anaesthesiology, and internal medicine were involved in preoperative optimization.

Hepatology consultation

The hepatology consultation confirmed stable liver graft function after two orthotopic LT performed in 1998 and 1999 owing to decompensated cirrhosis caused by chronic hepatitis B infection. Laboratory liver function tests remained within reference ranges, and no HBV replication was detected. The patient continued long-term immunosuppressive therapy with tacrolimus (Prograf; Astellas Pharma Inc., Tokyo, Japan) at a dose of 1.5 mg twice daily together with antiviral prophylaxis with lamivudine (Zeffix; GlaxoSmithKline, Poznan, Poland) 100 mg once daily. No perioperative interruption or dose reduction of tacrolimus was considered necessary because liver graft function remained stable. Additional hepatological therapy included ursodeoxycholic acid (Ursofalk; Dr. Falk Pharma GmbH, Freiburg, Germany) 500 mg once daily. The hepatology team recommended continuation of immunosuppressive and antiviral therapy during the perioperative period, with regular monitoring of liver function parameters.

Neurology consultation

A neurological consultation was performed owing to the patient’s history of ischemic stroke, encephalitis, and polyneuropathy. The neurological examination did not reveal contraindications to orthopaedic surgery or general anaesthesia. However, because of chronic antiplatelet therapy, temporary discontinuation of clopidogrel (75 mg daily) for at least 5 days before surgery was recommended to reduce the risk of perioperative bleeding.

Management of hyponatremia

The patient had a history of recurrent severe hyponatremia associated with SIADH. During previous hospitalization, serum sodium levels were corrected with hypertonic saline infusions. After stabilization of serum sodium concentration, outpatient pharmacological therapy with the vasopressin V2 receptor antagonist tolvaptan was initiated at a dose of 7.5 mg daily, which allowed maintenance of stable sodium levels before the planned orthopaedic surgery.

Anaesthesiology consultation

Preoperative anaesthesiology consultation classified the patient as American Society of Anaesthesiologists physical status IV owing to multiple severe comorbidities, including previous LT, cardiovascular disease, diabetes mellitus, and electrolyte disturbances. Extensive perioperative monitoring was recommended. Premedication with midazolam (7.5 mg) was administered before surgery. Regional analgesia was provided using an ultrasound-guided supra-inguinal fascia iliaca block with 30 mL of 0.5% ropivacaine to improve perioperative pain control. The procedure was subsequently performed under general anaesthesia with invasive blood pressure monitoring, central venous access, oxygen saturation monitoring, and respiratory gas analysis.

FINAL DIAGNOSIS

Recurrent dislocation of right THA with concomitant periprosthetic fracture in an elderly patient after two LT for chronic HBV infection.

TREATMENT

In preparation for the procedure, the patient was evaluated by multiple specialists within a multidisciplinary approach, which represented a considerable challenge for a single-specialty hospital. Specialists in hepatology, neurology, cardiology, anaesthesiology, endocrinology, and internal medicine were involved to optimize the patient’s condition before revision arthroplasty. On September 3, 2024, the patient underwent a right hip revision arthroplasty under general anaesthesia. During the surgical procedure, the pseudocapsule was excised, and adhesions were released, allowing for the identification of the dislocated components. The previously implanted cementless acetabulum and femoral stem were carefully removed owing to significant loosening. A cemented acetabular component and a cemented femoral stem were implanted. The greater trochanter was reconstructed using 40 cm³ of bone graft material. Appropriate drainage was established, and the wound was closed with sutures and metal staples.

On the day of the procedure, following premedication with midazolam 7.5 mg, the patient was transferred to the induction room of the operating suite, where a supra-inguinal fascia iliaca block was performed under ultrasound and neurostimulator guidance. A total of 30 mL of ropivacaine 0.5% was used for the block. The procedure was conducted under general anaesthesia with monitoring of the depth of anaesthesia, invasive blood pressure, central venous access, oxygen saturation, and respiratory gas analysis. The course of anaesthesia was uneventful. The patient was subsequently awakened and subsequently transferred to the postoperative ward. During a 2-day observation period, the patient’s condition remained stable, and laboratory tests showed no significant abnormalities. Recommended immunosuppressive therapy, antibiotic treatment, and pain management were continued. On the 3^rd day, the patient was transferred to the orthopaedic ward.

As revision hip arthroplasty is associated with an increased risk of bleeding and thromboembolic complications, perioperative blood management was carefully planned. As stated previously, chronic antiplatelet therapy with clopidogrel (75 mg daily) was discontinued 5 days before the surgery, according to neurological recommendations, to reduce the risk of perioperative bleeding. During the procedure, meticulous haemostasis was maintained, and no excessive intraoperative bleeding was reported. The exact numerical volume of intraoperative blood loss was not available in the retrospective medical records. However, in the early postoperative period, a significant decrease in haemoglobin concentration was observed, reaching 6 g/dL, which required transfusion of 3 units of packed red blood cells. Following transfusion, haemoglobin levels improved to approximately 10 g/dL at the time of discharge. No other haemorrhagic complications were observed. Postoperative thromboprophylaxis was implemented according to institutional protocol using low-molecular-weight heparin administered subcutaneously, together with early mobilization.

OUTCOME AND FOLLOW-UP

The first postoperative follow-up visit took place in October 2024. At that time, the patient’s general condition was stable, and the evaluated clinical parameters were satisfactory. A subsequent follow-up examination was performed 6 months later, in March 2025. During this visit, improvement in joint mobility and muscle strength was observed (Lovett grade III/IV), although the patient still required a walker for ambulation (Figure 1). A notable decrease in hip pain was reported. Pressure ulcers showed signs of healing. Densitometry results were within normal limits. The Harris Hip Score (HHS) was 68. The patient no longer reported hip pain and did not require analgesic medication, corresponding to a Visual Analog Scale (VAS) score of 0. The Short Form-12 (SF-12) score was 18. At the 6-month follow-up, no recurrent dislocation, periprosthetic infection, or implant-related complication was observed, and liver function remained stable. Subsequent densitometry did not demonstrate reduced bone mineral density. Osteoporosis-specific pharmacological therapy was not initiated.

Key laboratory parameters and functional scores in the preoperative, early postoperative, and follow-up periods are summarized in Table 1.

Table 1 Clinical and laboratory parameters before and after revision arthroplasty.

Parameter	Preoperative	Early postoperative	Follow-up
CRP in mg/L	82	Decreasing	Normal
Sodium in mmol/L	130	Stabilized	Normal
Liver function tests	Normal	Normal	Normal
Lovett grade muscle strength	I-II	Improved	III-IV
HHS	Not assessed	-	68
VAS	Severe pain	Improved	0
SF-12	Not assessed	-	18
Mobility	Unable to ambulate	Assisted mobilization	Walker-assisted ambulation

CRP: C-reactive protein; HHS: Harris Hip Score; SF-12: Short Form-12 Health Survey; VAS: Visual Analog Scale.

DISCUSSION

The increasing demand for THA in patients with chronic liver disease, who may ultimately require LT, remains a significant clinical challenge. In this population, bone undergoes biological and structural changes, accompanied by the development of systemic dysfunction[5]. Recent large database analyses confirm that arthroplasty in LT recipients is generally not associated with increased perioperative mortality; however, higher rates of readmission and medical complications such as acute kidney injury and sepsis have been reported. Additionally, chronic kidney disease and congestive heart failure appear to be important predictors of postoperative readmission in this population[6].

A systematic review conducted by Han et al[4], including 13 studies with 3024 patients, revealed that these individuals have markedly higher rates of complications, including infection, myocardial infarction, respiratory failure, acute kidney injury, sepsis, and the necessity for blood transfusions when compared to control groups. Despite these heightened risks, LT recipients show functional improvement after surgery, with significant gains in the HHS and Knee Society Scores. Overall, although patients experience beneficial outcomes with total hip and knee arthroplasties, these procedures carry notable risks that must be carefully managed.

Chronic liver disease significantly affects the hepatobiliary system and is associated with multiple complications, including hepatic osteodystrophy, increased susceptibility to infection, sarcopenia, and osteonecrosis of the femoral head (avascular necrosis). Hepatic osteodystrophy, characterized by decreased bone mineral density, can lead to osteoporosis and osteopenia. Patients with cirrhosis exhibit a 1.5-fold to 2-fold higher incidence of septic arthritis and a 10-fold increased need for THA owing to the increased risk of osteonecrosis of the femoral head[7].

Another retrospective study analysing 33 arthroplasty procedures performed in 20 LT recipients reported favourable perioperative outcomes. No cases of death, liver failure, or infection were observed within 30 days after surgery. Postoperative blood transfusion was required in 14 cases, with only 1 patient receiving more than 4 units of packed red blood cells. Additionally, all patients achieved good to excellent postoperative HHS. These findings suggest that hip arthroplasty can be safely performed in LT recipients, although perioperative transfusion may frequently be required[8].

A large database study comparing outcomes of THA in LT recipients and matched controls also demonstrated acceptable perioperative risk. LT recipients had a slightly longer hospital stay; however, no significant differences were observed in 30-day readmission rates, 90-day dislocation rates, or total costs of care within the first 90 days after surgery. These findings suggest that THA in LT recipients can be performed with outcomes comparable to those of the general population[9].

In the present case, the patient represented an extremely high-risk profile owing to advanced age, a history of two LT, chronic immunosuppressive therapy, and multiple comorbidities. Perioperative antithrombotic management in this patient required balancing the increased thromboembolic risk associated with revision arthroplasty against the risk of bleeding related to the extensive surgical procedure and chronic antiplatelet treatment. Clopidogrel was temporarily discontinued before surgery, whereas pharmacological thromboprophylaxis with low-molecular-weight heparin was introduced postoperatively. Additionally, significant perioperative blood loss was observed, requiring transfusion of 3 units of packed red blood cells after haemoglobin decreased to 6 g/dL. Such transfusion requirements are not uncommon in revision hip arthroplasty and reflect the complexity of these procedures in high-risk patients. LT may increase the risk of perioperative bleeding owing to impaired coagulation, thrombocytopenia, and altered hepatic synthetic function. Previous reports have demonstrated higher intraoperative blood loss and increased transfusion requirements in this patient population[10]. Several methods have been proposed to estimate perioperative blood loss following arthroplasty using changes in haemoglobin concentration and calculated circulating blood volume; however, reliable application of these methods requires complete serial laboratory and anthropometric data[11]. Preoperative planning, appropriate specialist consultations, and a multidisciplinary approach are essential. Surgical procedures should not be rushed, and patients should be optimally stabilized before surgery, especially when considering revision arthroplasty[12]. This is consistent with Enhanced Recovery After Surgery recommendations for LT, which emphasize that perioperative care should be based on a multidisciplinary approach aimed at reducing surgical stress and perioperative morbidity[13].

According to Chang et al[3], patients are at increased risk of osteoporosis and fractures after LT, particularly in the presence of additional risk factors such as advanced age and glucocorticoid therapy. Recent evidence further supports the clinical relevance of bone disease in this population. A large prospective study of 702 candidates for LT demonstrated that osteoporosis was present in over 40% of patients and was independently associated with increased waitlist mortality, highlighting bone mineral density as an important prognostic factor in patients with advanced liver disease[14]. These findings suggest that bone fragility in LT recipients reflects not only skeletal deterioration but also overall frailty and reduced physiological reserve. In the present case, multiple risk factors for secondary osteoporosis were present, including advanced age, long-term immunosuppressive therapy, and reduced mobility. However, no densitometric evidence of osteoporosis was observed during follow-up.

In addition to osteoporosis-related factors, our patient suffered from chronic hyponatremia caused by SIADH. Hyponatremia contributes to fractures by causing gait instability and increasing bone fragility[15].

Furthermore, our patient was treated with tacrolimus. Lifelong immunosuppressive therapy may increase susceptibility to postoperative complications, particularly infections and renal dysfunction. Several studies have reported higher rates of acute kidney injury and systemic infections in transplant recipients undergoing arthroplasty, which may contribute to prolonged hospitalization and increased morbidity[16]. Previous reports suggest a possible association between tacrolimus and SIADH, although the mechanism remains unclear[17,18]. According to Capinha et al[19], this mechanism may involve renal salt-losing nephropathy and downregulation of mineralocorticoid receptor expression, leading to impaired aldosterone activity and sodium loss. This mechanism may mimic SIADH and contribute to chronic hyponatremia in transplant recipients. Additionally, long-term immunosuppressive therapy may contribute to increased bone resorption and fracture risk[20].

Another important aspect in this case is the revision nature of the procedure. Revision THA is associated with longer operative time, greater blood loss, and higher complication rates compared with primary arthroplasty, which further increases perioperative risk in transplant recipients. Therefore, careful perioperative optimization and individualized surgical planning are essential in this subgroup of patients.

Although this report presents a single case, available literature suggests that THA in LT recipients can provide meaningful functional improvement despite increased perioperative risk. However, data regarding revision arthroplasty in patients after multiple LT remain limited. Further studies, including multicentre case series, are needed to better define optimal perioperative management and long-term outcomes in this high-risk population. Despite the very high perioperative risk, a favourable clinical outcome was achieved. This case highlights the importance of individualized treatment planning and multidisciplinary perioperative management.

CONCLUSION

The experience with this patient underscores the critical need for personalized approaches in managing revision hip arthroplasty among LT recipients, especially those with complex comorbidities. These patients should be treated in multidisciplinary centres and evaluated by appropriate specialists. While standard protocols often dictate surgical interventions for femoral neck fractures or endoprosthesis dislocation, the unique health status of this population necessitates a thorough evaluation of the risks and benefits associated with both surgical and conservative management. Optimal management of comorbidities enables better decision-making regarding surgical treatment.

This case demonstrates that, despite the inherent risks associated with immunosuppression, patients can achieve significant functional improvements following revision hip arthroplasty, as measured by HHS, SF-12, and VAS scores, when careful preoperative assessment and structured postoperative management (including close monitoring in a specialized postoperative ward with anaesthesiology supervision) are implemented. Additionally, this report highlights the importance of individualized multidisciplinary collaboration in the care of such patients, integrating input from orthopaedic, aesthetic, and transplant teams to optimize surgical outcomes. Chronic hyponatremia can lead to osteoporosis and an increased risk of fractures. In LT recipients receiving calcineurin inhibitors such as tacrolimus and glucocorticosteroids, early osteoporosis prevention should be considered, especially in the presence of additional risk factors.

Future studies should aim to develop practical guidelines for managing similar cases, balancing standardized care with individual patient needs and evaluating both clinical and quality-of-life outcomes.

ACKNOWLEDGEMENTS

The authors thank the medical and nursing staff involved in the care of this patient.